Popliteal Cysts: Historical Background

and Current Knowledge

Walton W. Curl, MD

Abstract
Popliteal cysts were first described in 1840 by Adams, but it is from Bakers
writing in 1877 that we derive the commonly used eponymic term Bakers cyst.
Associated intra-articular lesions are very common with popliteal cysts. Ultrasonography, arthrography, and magnetic resonance imaging have all proved useful in distinguishing popliteal cysts from other cysts and from soft-tissue tumors
about the knee, as well as in identifying coexisting intra-articular lesions. Cysts
in pediatric patients are generally self-limited and should be treated conservatively. In the adult population, treatment is primarily nonsurgical. Arthroscopic
evaluation is indicated if an intra-articular lesion is causing mechanical symptoms or if there is no response to appropriate conservative treatment, such as use
of nonsteroidal anti-inflammatory drugs and compression sleeves. Surgical excision is reserved for cases in which this approach has been unsuccessful.
J Am Acad Orthop Surg 1996;4:129-133

Popliteal cysts were first described

over a century and a half ago. Despite our increasing knowledge of
their etiology, pathology, and clinical course, they remain something of
a clinical enigma.

Historical Background
A popliteal cyst was first described by
Adams in 1840 as an enlarged bursa
that is normally situated beneath the
inner head of the gastrocnemius and
communicates with the joint by a
species of valvular opening.1 In
1856, Foucher described a recurrent
cyst and noted that it became firm
with full knee extension and soft with
knee flexion. This pattern is now
known as Fouchers sign.2
In 1877, Baker further delineated
the entity as being caused by trapping
of fluid in a bursa related to the semi-

Vol 4, No 3, May/June 1996

membranosus tendon, which causes

the bursa to distend. He asserted that
the cyst communicates with the joint
synovium and that fluid then leaks
into the bursa but cannot flow in the
reverse direction. He also described
the occurrence of a ruptured bursa
that simulated venous thrombosis.
After his description, Bakers name
became associated with the clinical
entity of a popliteal cyst.1
In the early part of the 20th century,
a number of other important observations were made. The most notable
was made by Wilson in 1938,1 who
noted in anatomic dissections that the
bursa under the medial head of the
gastrocnemius and the bursa under
the semimembranosus often connect.
He concluded that most popliteal
cysts result from distention of this gastrocnemius-semimembranosus bursa.
In 1973, Taylor and Rana 3 reported that postmortem dissections

of 50 knees showed a valvular communication between the medial gastrocnemius bursa and the joint. In
1977, Lindgren et al4 demonstrated
that with age there is an increasing
frequency of communication with
the joint, attributable primarily to
thinning of the posterior joint capsule and progressive degradation of
the capsule.
Although popliteal cysts may occur on the lateral side of the knee,
they typically arise from the bursa
associated with the popliteus tendon. Therefore, the term Bakers
cyst is more appropriately used to
describe only those cysts that occur
on the posteromedial aspect of the
knee between the medial head of
the gastrocnemius and the semimembranosus tendon. There is historically a high association of
intra-articular lesions with popliteal
cysts. All of Bakers cases were associated with either tuberculosis of
the knee or a Charcot joint.1 Rheumatoid arthritis, osteoarthritis,

Dr. Curl is Associate Professor, Department of

Orthopaedic Surgery, Bowman Gray School of
Medicine, Winston-Salem, NC.
Reprint requests: Dr. Curl, Bowman Gray
School of Medicine, Orthopaedic Surgery and
Rehabilitation, Medical Center Boulevard, Winston-Salem, NC 27157-1070.
Copyright 1996 by the American Academy of Orthopaedic Surgeons.

129

Popliteal Cysts
meniscal tears, and conditions that
can cause synovitis have been reported to be associated with the formation of popliteal cysts.

Pathology
The pathologic findings in a popliteal
cyst are quite similar to those found
in a ganglion cyst. Popliteal cysts are
generally lined with flattened,
mesothelium-like cells surrounded
by fibroblasts and lymphocytes.
Hyaline and fibrocartilage elements
may be found in parts of the wall.
The fluid is generally viscous, with
copious amounts of fibrin.
Burleson categorized cysts into
three main types.5 Type 1 cysts are fibrous, have a wall measuring only 1
to 2 mm thick, and are lined with flattened, mesothelium-like cells. Type 2
cysts have less well-defined, thicker
walls that blend with the surrounding connective tissue. There is generally more lobulation within the cyst,
and the cells are more cuboid than in
type 1 cysts. Type 3 cysts have walls
that are as much as 8 mm thick and
that have more lymphocytes, plasma
cells, and histiocytes than the walls of
type 1 and type 2 cysts. This inflammatory response is more pronounced
in patients with rheumatoid arthritis.

Clinical Presentation
A popliteal cyst typically presents as
a mass in the posteromedial aspect of
the knee. In pediatric patients,
masses are usually asymptomatic
and are often brought to the physicians attention by a parent concerned about a bulge in the region of
the posterior popliteal fossa. In older
patients, attention is often drawn to
the mass because of an achy sensation
in the posterior portion of the knee
during exercise and a fullness noted
in the knee on flexion and extension.
These symptoms can be isolated but

130

are more commonly combined with

symptoms related to underlying
pathologic conditions, such as degenerative joint disease, patellofemoral
arthrosis, meniscal disease, or torn
anterior cruciate ligament.6 Symptoms often include pain along the medial joint line and a sensation of
giving way, especially when walking
for long periods of time or when going up or down stairs.
Rupture of a popliteal cyst can occur suddenly, causing severe pain behind the knee and considerable
swelling in the calf region. This combination has been called pseudothrombophlebitis syndrome,
because the signs and symptoms are
often indistinguishable from those of
thrombophlebitis, even presenting
with a positive Homans sign and tenderness over the posterior aspect of
the calf.7 A ruptured cyst can sometimes be differentiated from thrombophlebitis clinically. In patients with
thrombophlebitis, there may be a
hard, palpable cord corresponding to
the thrombosed vein, which is not
present with a ruptured popliteal cyst.
Because a chronic dissection or
leakage of a popliteal cyst can form a
symmetrical, cylindrical swelling in
the posterior region of the calf,
which can extend all the way to the
ankle, confusion with deep vein
thrombosis is common. The definitive diagnosis of deep vein thrombosis requires confirmation with
venous Doppler sonography or
venography.
Malignant lesions of the popliteal
fossa are rare. However, there are
reports in the literature of fibrosarcoma, synovial sarcoma, or malignant fibrous histiocytoma being
mistaken for a popliteal cyst.8

Diagnosis
Because popliteal cysts can be mimicked by other conditions, careful
clinical evaluation is essential. Plain

radiographs are frequently normal,

although soft-tissue swelling can
sometimes be detected. Arthrography often demonstrates a communication between the joint and the
popliteal cyst and has been used to
correctly identify popliteal cysts in
10% to 41% of patients.8 False-positive diagnoses may occur if the bursa
is distended by the arthrographic
dye. Arthrographic studies have
also confirmed that the incidence of
these cysts increases with age.
Ultrasonography has long been
used as a noninvasive technique for
evaluation of popliteal cysts, with
reliability comparable to that of
arthrography and magnetic resonance (MR) imaging.9-11 Although
ultrasonography has been superseded in frequency of use (but not
necessarily in usefulness and accuracy) by MR imaging, it continues to
have a role in diagnosis. The ultrasound study can be useful in distinguishing cystic lesions from solid
masses in the posterior fossa of the
knee.12
Since the introduction of MR
imaging, the reported incidences of
true popliteal cysts have been much
lower than previously estimated. In
a recent study, Fielding et al 6 reviewed 1,127 MR imaging examinations and found that the prevalence
of popliteal cysts was 5% overall and
that it increased with age. They also
found that 82% of popliteal cysts
were associated with a meniscal tear,
most commonly a tear of the posterior portion of the medial meniscus;
only 38% of the tears involved the
lateral meniscus. An anterior cruciate ligament tear was present in 13%
of the subjects. A low prevalence of
popliteal cysts was found in the pediatric age group; however, the
study was retrospective and included only five patients younger
than 10 years of age.
Magnetic resonance imaging has
enhanced our ability to distinguish
popliteal cysts from solid lesions and

Journal of the American Academy of Orthopaedic Surgeons

Walton W. Curl, MD

tumors in the popliteal region. Although generally more expensive than

other radiologic techniques, it is certainly being used increasingly for assessing cystic lesions about the knee.
Because of the high content of free water, the MR imaging features of a
popliteal cyst are low signal intensity
on T1-weighted images and high signal intensity on T2-weighted images
(Fig. 1). There are often septa within
popliteal cysts. Hemorrhage, loose
bodies, and debris may also be found.13
A popliteal cyst can usually be
easily differentiated from a cyst of
either the lateral or the medial
meniscus. Meniscal cysts typically
demonstrate a communicating tear
in the periphery of the meniscus,
and the cyst is usually more medial
or more lateral than a true popliteal
cyst, which occurs between the medial head of the gastrocnemius and
the semimembranosus tendon.14

In the adult population, popliteal cysts

are often associated with intra-articular lesions. 15 Ultrasonography,
arthrography, and MR imaging have
all proved useful in diagnosis. Aspira-

tion of the cyst may also be performed

for both diagnostic purposes and treatment. Some authors1 advocate injecting corticosteroids into a popliteal cyst.
In my experience, however, neither
cyst aspiration nor corticosteroid injection is more than a temporizing measure; the cyst generally recurs unless
the intra-articular disorder associated
with it is addressed. If no intra-articular lesion is present, the cyst can be
treated symptomatically and followed
conservatively.
Arthroscopic evaluation is indicated if an intra-articular lesion is
causing mechanical symptoms and is
not responding to nonsurgical treatment, such as nonsteroidal anti-inflammatory drugs, use of compression
sleeves, and physical therapy, or if
pain or persistent swelling interferes
with function. Treatment of the intraarticular disorder often leads to resolution of the cyst as well. Jayson et al16
reported reliable results with anterior
synovectomy in patients with
rheumatoid arthritis.
If the popliteal cyst does not respond to conservative measures or
arthroscopic intervention, an open
excision may be necessary. A stalk
leading from the cyst down to the
joint can often be located and su-

Treatment

Fig. 1 A, Axial T2-weighted MR image of the knee demonstrates a posteromedial cyst (C)
between the medial head of the gastrocnemius (G) and the semimembranosus tendon (S).
B, Sagittal T2-weighted MR image depicts a large posterior popliteal cyst (C).

Vol 4, No 3, May/June 1996

tured over or cauterized, after

which the cyst can be removed.
The recurrence rate can be quite
high, however, particularly when
the articular lesion remains uncorrected. In the 1979 series of
Rauschning and Lindgren,17 a recurrent cyst was found in 63% of
the 40 patients. The authors attributed this primarily to the difficulty
of obtaining tight closure of the
capsule, which allowed fluid to
leak and re-form the cyst. In a later
series, Rauschning18 modified his
technique to include arthroscopic
evaluation and treatment of intraarticular lesions and use of a posteromedial approach for exposure.
He emphasized closure of the communication and performed a partial gastrocnemius-pedicle graft to
reinforce the capsular repair. There
were no recurrences and no postoperative complications in this
small series of eight patients.
Hughston et al19 described a similar surgical approach (Fig. 2) in
their series of 30 patients, only 2 of
whom had recurrences. A posteromedial approach is made through a
medial hockey-stick incision with
the knee flexed at a 90-degree angle.
The capsular incision begins between the medial epicondyle and
the adductor tubercle and is extended distally along the posterior
edge of the tibial collateral ligament,
anterior to the popliteal oblique ligament. The posterior oblique ligament is then retracted posteriorly.
The cyst is usually found between
the semimembranosus tendon and
the medial head of the gastrocnemius. The capsular origin of the cyst
is identified, and the cyst is dissected free of its surrounding adhesions and excised. The rent in the
capsule is repaired with nonabsorbable sutures. The capsule can
be reinforced with a pedicle flap
from the medial head of the gastrocnemius as Rauschning described,18
if the surgeon so chooses. The

131

Popliteal Cysts

Quadriceps

Adductor tubercle
Medial epicondyle
Tibial
collateral
ligament

Adductor
Medial head of
gastrocnemius
Sartorius

Retinaculum
Posterior
oblique
ligament

Gracilis

Hockeystick
incision

Semitendinosus

Oblique popliteal ligament

Gastrocnemius
Semimembranosus

Fig. 2 A, Medial hockeystick incision and underlying

anatomic structures in right
knee. B, Area exposed by incision. Skin and subcutaneous tissues have been
removed to demonstrate relationship of popliteal cyst to
anterior medial retinacular
incision (AB) and posterior
capsular incision (CD). Posterior oblique ligament can
be retracted posteriorly for
inspection of medial meniscus and intra-articular aspect
of posterior capsule. C,
Opening and retraction of
cyst demonstrates adherence
to surrounding tissues. Cyst
can then be isolated and excised in its entirety.

Medial head of
gastrocnemius

A
C

Semimembranosus

Posterior
oblique

Semimembranosus

Popliteal cyst
Medial
meniscus

Tibial collateral ligament

B

wound is then closed, and the knee

is immobilized for 48 hours, with
weight-bearing as tolerated.
In the pediatric age group, popliteal
cysts are generally benign and self-limited. They are rarely associated with
intra-articular lesions and are often
asymptomatic. If the diagnosis is in
doubt, ultrasonography or MR imaging can be used to pinpoint the diagnosis and rule out soft-tissue tumors in
the region. As previously pointed out,
ultrasonography is generally considered very reliable and is less expensive

132

than MR imaging. Most pediatric cysts

resolve spontaneously, and surgery is
not indicated.20

Summary
Popliteal cysts commonly occur between the gastrocnemius muscle
and the semimembranosus tendon.
They are generally associated with
intra-articular lesions, such as osteoarthritis or a degenerative meniscal tear. They are also very common
in association with rheumatoid

arthritis. Magnetic resonance imaging can easily distinguish a popliteal

cyst from another mass about the
knee, such as a meniscal cyst, ganglion, or soft-tissue tumor. Conservative management is the treatment
of choice. Arthroscopy is indicated
for intra-articular symptoms. If a
cyst is resistant to conservative treatment or arthroscopy, excision may
be necessary. In the pediatric age
group, popliteal cysts are generally
self-limited and should be treated
conservatively.

Journal of the American Academy of Orthopaedic Surgeons

Walton W. Curl, MD

References
1. Wigley RD: Popliteal cysts: Variations
on a theme of Baker. Semin Arthritis
Rheum 1982;12:1-10.
2. Canoso JJ, Goldsmith MR, Gerzof SG, et
al: Fouchers sign of the Bakers cyst.
Ann Rheum Dis 1987;46:228-232.
3. Taylor AR, Rana NA: A valve: An explanation of the formation of popliteal
cysts. Ann Rheum Dis 1973;32:419-421.
4. Lindgren PG, Willn R: Gastrocnemiosemimembranosus bursa and its relation to the knee joint: I. Anatomy and
histology. Acta Radiol [Diagn] (Stockh)
1977;18:497-512.
5. Burleson RJ, Bickel WH, Dahlin DC: Popliteal cyst: A clinicopathological survey.
J Bone Joint Surg Am 1956;38:1265-1274.
6. Fielding JR, Franklin PD, Kustan J:
Popliteal cysts: A reassessment using
magnetic resonance imaging. Skeletal
Radiol 1991;20:433-435.
7. Katz RS, Zizic TM, Arnold WP, et al:
The pseudothrombophlebitis syndrome. Medicine 1977;56:151-164.

Vol 4, No 3, May/June 1996

8. Bogumill GP, Bruno PD, Barrick EF:

Malignant lesions masquerading as
popliteal cysts: A report of three cases. J
Bone Joint Surg Am 1981;63:474-477.
9. stergaard M, Court-Payen M, Gideon
P, et al: Ultrasonography in arthritis of
the knee: A comparison with MR imaging. Acta Radiol 1995;36:19-26.
10. Richardson ML, Selby B, Montana MA,
et al: Ultrasonography of the knee. Radiol Clin North Am 1988;26:63-75.
11. Hermann G, Yeh HC, Lehr-Janus C, et
al: Diagnosis of popliteal cyst: Doublecontrast arthrography and sonography.
AJR Am J Roentgenol 1981;137:369-372.
12. Toolanen G, Lorentzon R, Friberg S, et
al: Sonography of popliteal masses.
Acta Orthop Scand 1988;59:294-296.
13. Janzen DL, Peterfy CG, Forbes JR, et al:
Cystic lesions around the knee joint: MR
imaging findings. AJR Am J Roentgenol
1994;163:155-161.
14. Lantz B, Singer KM: Meniscal cysts.
Clin Sports Med 1990;9:707-725.

15. Wolfe RD, Colloff B: Popliteal cysts: An

arthrographic study and review of the
literature. J Bone Joint Surg Am
1972;54:1057-1063.
16. Jayson MIV, Dixon AStJ, Kates A, et al:
Popliteal and calf cysts in rheumatoid
arthritis: Treatment by anterior synovectomy. Ann Rheum Dis 1972;31:
9-15.
17. Rauschning W, Lindgren PG: Popliteal
cysts (Bakers cysts) in adults: I. Clinical
and roentgenological results of operative excision. Acta Orthop Scand
1979;50:583-591.
18. Rauschning W: Popliteal cysts (Bakers
cysts) in adults: II. Capsuloplasty with
and without a pedicle graft. Acta Orthop
Scand 1980;51:547-555.
19. Hughston JC, Baker CL, Mello W:
Popliteal cyst: A surgical approach. Orthopedics 1991;14:147-150.
20. Dinham JM: Popliteal cysts in children:
The case against surgery. J Bone Joint
Surg Br 1975;57:69-71.

133